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Where There Is No Doctor


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Where There Is No Doctor

  1. 1. Contents A list of what is discussed in each chapter INTRODUCTION NOTE ABOUT THIS NEW EDITION WORDS TO THE VILLAGE HEALTH WORKER (Brown Pages). . . . . . . . . . . . . .w1 Health Needs and Human Needs w2 A Balance Between Prevention and Many Thing Relate to Health Care w7 Treatment w17 Take a Good Look at Your Community w8 Sensible and Limited Use of Medicines w18 Using Local Resources to Meet Needs w12 Finding Out What Progress Has Been Deciding What to Do and Where to Made w20 Begin w13 Teaching and Learning Together w21 Trying a New Idea w15 Tools for Teaching w22 A Balance Between People and Land w16 Making the Best Use of This Book w28 Chapter 1 HOME CURES AND POPULAR BELIEFS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Home Cures That Help 1 Ways to Tell Whether a Home Remedy Beliefs That Can Make People Well 2 Works or Not 10 Beliefs That Can Make People Sick 4 Medicinal Plants 12 Witchcraft—Black Magic—and the Evil Eye 5 Homemade Casts—for Broken Bones 14 Questions and Answers 6 Enemas, Laxatives, and Purges 15 Sunken Fontanel or Soft Spot 9 Chapter 2 SICKNESSES THAT ARE OFTEN CONFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 What Causes Sickness? 17 Example of Local Names for Sicknesses 22 Different Kinds of Sicknesses and Their Misunderstanding Due to Confusion of Causes 18 Names 25 Non-infectious Diseases 18 Confusion between Different illnesses That Infectious Diseases 19 Cause Fever 26 Sicknesses That Are Hard to Tell Apart 20 Chapter 3 HOW TO EXAMINE A SICK PERSON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Questions 29 Eyes 33 General Condition of Health 30 Ears 34 Temperature 30 Skin 34 How to Use a Thermometer 31 The Belly (Abdomen) 35 Breathing (Respiration) 32 Muscles and Nerves 37 Pulse (Heartbeat) 32
  2. 2. Chapter 4 HOW TO TAKE CARE OF A SICK PERSON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 The Comfort of the Sick Person 39 Watching for Changes 41 Special Care for a Person Who Is Very Ill 40 Signs of Dangerous Illness 42 Liquids 40 When and How to Look for Medical Help 43 Food 41 What to Tell the Health Worker 43 Cleanliness and Changing Position in Bed 41 Patient Report 44 Chapter 5 HEALING WITHOUT MEDICINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Healing with Water 46 When Water Is Better than Medicines 47 Chapter 6 RIGHT AND WRONG USE OF MODERN MEDICINES. . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Guidelines for the Use of Medicine 49 When Should Medicine Not Be Taken? 54 The Most Dangerous Misuse of Medicine 50 Chapter 7 ANTIBIOTICS: WHAT THEY ARE AND HOW TO USE THEM . . . . . . . . . . . . . . . . . . . . . . 55 Guidelines for the Use of Antibiotics 56 What to Do if an Antibiotic Does Not Seem to Help 57 Importance of Limited Use of Antibiotics 58 Chapter 8 HOW TO MEASURE AND GIVE MEDICINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Medicine in Liquid Form 61 Dosage Instructions for Persons Who How to Give Medicines to Small Children 62 Cannot Read 63 How to Take Medicines 63 Chapter 9 INSTRUCTIONS AND PRECAUTIONS FOR INJECTIONS. . . . . . . . . . . . . . . . . . . . . . . . 65 When to Inject and When Not To 65 Avoiding Serious Reactions to Penicillin 71 Emergencies When It Is Important to Give How to Prepare a Syringe for Injection 72 Injections 66 How to Inject 73 Medicines Not to Inject 67 How Injections Can Disable Children 74 Risks and Precautions 68 How to Sterilize Equipment 74 Dangerous Reactions From Injecting Certain Medicines 70
  3. 3. Chapter 10 FIRST AID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Infected Wounds 88 Protection 75 Basic Cleanliness and Infected Wounds 88 Bullet, 75 Fever Knife, and Other Serious Wounds 90 Bullet, Knife, and Other Serious Wounds 90 Shock 77 Emergency Problems of the Gut Emergency Problems of the Gut of Consciousness 78 Loss (Acute Abdomen) 93 (Acute Abdomen) 93 Appendicitis, Peritonitis 94 in the When Something Gets Stuck Appendicitis, Peritonitis 94 Burns 96 Throat 79 Burns 96 Drowning 79 Broken Bones (Fractures) 98 Broken Bones (Fractures) 98 How to Move a Badly Injured Person 100 When Breathing Stops: Mouth-to-Mouth How to Move a Badly Injured Person 100 Breathing 80 Dislocations Dislocations (Bones out of Place Heat 81 Emergencies Caused by at a Joint) 101 (Bones out of Place at a Joint) 101 Strains and Sprains 102 from a Wound 82 How to Control Bleeding Strains and Sprains 102 How to Stop Nosebleeds 83 CPoisoning 103 Poisoning 103 Snakebite 104 and Small Wounds 84 Cuts, Scrapes, Snakebite 104 Other Poisonous Bites andThem 85 Large Cuts: How to Close Stings 106 Other Poisonous Bites and Stings 106 Bandages 87 Chapter 11 NUTRITION: WHAT TO EAT TO BE HEALTHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Sicknesses Caused by Not Eating Well 107 Special Diets for Specific Health Why It Is Important to Eat Right 109 Problems 124 Preventing Malnutrition 109 Anemia 124 Main Foods and Helper Foods 110 Rickets 125 Eating Right to Stay Healthy 111 High Blood Pressure 125 How to Recognize Malnutrition 112 Fat People 126 Eating Better When You Do Not Have Much Constipation 126 Money or Land 115 Diabetes 127 Where to Get Vitamins: In Pills or Acid Indigestion, Heartburn, and Stomach in Foods? 118 Ulcers 128 Things to Avoid in Our Diet 119 Goiter The Best Diet for Small Children 120 (A Swelling or Lump on the Throat) 130 Harmful Ideas about Diet 123 Chapter 12 PREVENTION: HOW TO AVOID MANY SICKNESSES . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Cleanliness—and Problems from Lack of Trichinosis 144 Cleanliness 131 Amebas 144 Basic Guidelines of Cleanliness 133 Giardia 145 Sanitation and Latrines 137 Blood Flukes Worms and Other Intestinal Parasites 140 (Schistosomiasis, Bilharzia) 146 Roundworm (Ascaris) 140 Vaccinations (lmmunizations)—Simple, Sure Pinworm (Threadworm, Enterobius) 141 Protection 147 Whipworm (Trichuris) 142 Other Ways to Prevent Sickness and Injury 148 Hookworm 142 Habits That Affect Health 148 Tapeworm 143
  4. 4. Chapter 13 SOME VERY COMMON SICKNESSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Dehydration 151 Bronchitis 170 Diarrhea and Dysentery 153 Pneumonia 171 The Care of a Person with Acute Diarrhea 160 Hepatitis 172 Vomiting 161 Arthritis (Painful, Inflamed Joints) 173 Headaches and Migraines 162 Back Pain 173 Colds and the Flu 163 Varicose Veins 175 Stuffy and Runny Noses 164 Piles (Hemorrhoids) 175 Sinus Trouble (Sinusitis) 165 Swelling of the Feet and Other Parts of the Hay Fever (Allergic Rhinitis) 165 Body 176 Allergic Reactions 166 Hernia (Rupture) 177 Asthma 167 Seizures (Fits, Convulsions) 178 Cough 168 Chapter 14 SERIOUS ILLNESSES THAT NEED SPECIAL MEDICAL ATTENTION . . . . . . . . . . . .179 Tuberculosis (TB, Consumption) 179 Dengue (Breakbone Fever, Dandy Rabies 181 Fever) 187 Tetanus (Lockjaw) 182 Brucellosis (Undulant Fever, Malta Fever) 188 Meningitis 185 Typhoid Fever 188 Malaria 186 Typhus 190 Leprosy (Hansen’s Disease) 191 Chapter 15 SKIN PROBLEMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .193 General Rules for Treating Skin Problems 193 Warts (Verrucae) 210 Instructions for Using Hot Compresses 195 Corns 210 Identifying Skin Problems 196 Pimples and Blackheads (Acne) 211 Scabies 199 Cancer of the Skin 211 Lice 200 Tuberculosis of the Skin or Lymph Bedbugs 200 Nodes 212 Ticks and Chiggers 201 Erysipelas and Cellulitis 212 Small Sores with Pus 201 Gangrene (Gas Gangrene) 213 Impetigo 202 Ulcers of the Skin Caused by Poor Boils and Abscesses 202 Circulation 213 Itching Rash, Welts, or Hives 203 Bed Sores 214 Things That Cause Itching or Burning of the Skin Problems of Babies 215 Skin 204 Eczema Shingles (Herpes Zoster) 204 (Red Patches with Little Blisters) 216 Ringworm, Tinea (Fungus Infections) 205 Psoriasis 216 White Spots on the Face and Body 206 Mask of Pregnancy 207 Pellagra and Other Skin Problems Due to Malnutrition 208
  5. 5. Chapter 16 THE EYES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Danger Signs 217 Trouble Seeing Clearly 223 Injuries to the Eye 218 Cross-Eyes and Wandering Eyes 223 How to Remove a Speck of Dirt from the Sty (Hordeolum) 224 Eye 218 Pterygium 224 Chemical Burns of the Eye 219 A Scrape, Ulcer, or Scar on the Cornea 224 Red, Painful Eyes—Different Causes 219 Bleeding in the White of the Eye 225 ‘Pink Eye’ (Conjunctivitis) 219 Bleeding behind the Cornea (Hyphema) 225 Trachoma 220 Pus behind the Cornea (Hypopyon) 225 Infected Eyes in Newborn Babies Cataract 225 (Neonatal Conjunctivitis) 221 Night Blindness and Xerophthalmia 226 Iritis (Inflammation of the Iris) 221 Spots or ‘Flies’ before the Eyes 227 Glaucoma 222 Double Vision 227 Infection of the Tear Sac River Blindness (Onchocerciasis) 227 (Dacryocystitis) 223 Chapter 17 THE TEETH, GUMS, AND MOUTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 Care of Teeth and Gums 229 Sores or Cracks at the Corners of the If You Do Not Have A Toothbrush 230 Mouth 232 Toothaches and Abscesses 231 White Patches or Spots in the Mouth 232 Pyorrhea, a Disease of the Gums 231 Cold Sores and Fever Blisters 232 Chapter 18 THE URINARY SYSTEM AND THE GENITALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233 Urinary Tract Infections 234 Use of a Catheter to Drain Urine 239 Kidney or Bladder Stones 235 Problems of Women 241 Enlarged Prostate Gland 235 Vaginal Discharge 241 Diseases Spread by Sexual Contact How a Woman Can Avoid Many (Sexually Transmitted Infections) 236 Infections 242 Gonorrhea (Clap, VD, the Drip) and Pain or Discomfort in a Woman’s Belly 243 Chlamydia 236 Men and Women Who Cannot Have Children Syphilis 237 (Infertility) 244 Bubos: Bursting Lymph Nodes in the Groin 238 Chapter 19 INFORMATION FOR MOTHERS AND MIDWIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245 The Menstrual Period How to Stay Healthy during Pregnancy 247 (Monthly Bleeding in Women) 245 Minor Problems during Pregnancy 248 The Menopause Danger Signs in Pregnancy 249 (When Women Stop Having Periods) 246 Check-ups during Pregnancy Pregnancy 247 (Prenatal Care) 250
  6. 6. Record of Prenatal Care 253 Tearing of the Birth Opening 269 Things to Have Ready before the Birth 254 Care of the Newborn Baby 270 Preparing for Birth 256 Illnesses of the Newborn 272 Signs That Show Labor Is Near 258 The Mothers Health after Childbirth 276 The Stages of Labor 259 Childbirth Fever Care of the Baby at Birth 262 (Infection after Giving Birth) 276 Care of the Cut Cord (Navel) 263 Care of the Breasts 277 The Delivery of the Placenta (Afterbirth) 264 Lumps or Growths in the Lower Part of the Hemorrhaging (Heavy Bleeding) 264 Belly 280 The Correct Use of Oxytocics: Miscarriage (Spontaneous Abortion) 281 Ergonovine, Oxytocin, Pitocin, etc. 266 High Risk Mothers and Babies 282 Difficult Births 267 Chapter 20 FAMILY PLANNING— HAVING THE NUMBER OF CHILDREN YOU WANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283 Choosing a method of Family Planning 284 Methods for Those Who Never Want to Have Oral Contraceptives More Children 293 (Birth Control Pills) 286 Home Methods for Preventing Other Methods of Family Planning 290 Pregnancy 294 Combined Methods 292 Chapter 21 HEALTH AND SICKNESSES OF CHILDREN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295 What to Do to Protect Children’s Mumps 312 Health 295 Whooping Cough 313 Children’s Growth— Diphtheria 313 and the ‘Road to Health’ 297 Infantile Paralysis (Polio) 314 Child Health Chart 298 How to Make Simple Crutches 315 Review of Children’s Health Problems Problems Children Are Born With 316 Discussed in Other Chapters 305 Dislocated Hip 316 Health Problems of Children Not Umbilical Hernia Discussed in Other Chapters 309 (Belly Button That Sticks Out) 317 Earache and Ear Infections 309 A ‘Swollen Testicle’ Sore Throat and Inflamed Tonsils 309 (Hydrocele or Hernia) 317 Rheumatic Fever 310 Mentally Slow, Deaf, or Deformed Infectious Diseases of Childhood 311 Children 318 Chickenpox 311 The Spastic Child (Cerebral Palsy) 320 Measles (Rubeola) 311 Retardation in the First Months of Life 321 German Measles (Rubella) 312 Sickle Cell Disease 321 Helping Children Learn 322
  7. 7. Chapter 22 HEALTH AND SICKNESSES OF OLDER PEOPLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323 Summary of Health Problems Discussed in Deafness 327 Other Chapters 323 Loss of Sleep (Insomnia) 328 Other Important Illnesses of Old Age 325 Diseases Found More Often in People over Heart Trouble 325 Forty 328 Words to Younger Persons Who Want to Cirrhosis of the Liver 328 Stay Healthy When Older 326 Gallbladder Problems 329 Stroke (Apoplexy, Cerebro-Vascular Accepting Death 330 Accident, CVA) 327 Chapter 23 THE MEDICINE KIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331 How to Care for Your Medicine Kit 332 The Village Medicine Kit 336 Buying Supplies for the Medicine Kit 333 Words to the Village Storekeeper The Home Medicine Kit 334 (or Pharmacist) 338 THE GREEN PAGES—The Uses, Dosage, and Precautions for Medicines . . . . . . . 339 List of Medicines in the Green Pages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341 Index of Medicines in the Green Pages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345 Information on Medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351 THE BLUE PAGES-New information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399 HIV and AIDS 399 Guinea Worm 406 Sores on the Genitals 402 Emergencies Caused by Cold 408 Circumcision and Excision 404 How to Measure Blood Pressure 410 Special Care for Small, Early, Poisoning from Pesticides 412 and Underweight Babies 405 Complications from Abortion 414 Ear Wax 405 Drug Abuse and Addiction 416 Leishmaniasis 406 VOCABULARY—Explaining Difficult Words . . . . . . . . . . . . . . . . . . . . . 419 ADDRESSES FOR TEACHING MATERIALS. . . . . . . . . . . . . . . . . . . . . . 429 INDEX (Yellow Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433 Dosage Instructions for Persons Who Cannot Read Making Medical Reports Information About Vital Signs
  8. 8. IntroduCtIon This handbook has been written primarily for those who live far from medical centers, in places where there is no doctor. But even where there are doctors, people can and should take the lead in their own health care. So this book is for everyone who cares. It has been written in the belief that: 1. Health care is not only everyone’s right, but everyone’s responsibility. 2. Informed self-care should be the main goal of any health program or activity. 3. Ordinary people provided with clear, simple information can prevent and treat most common health problems in their own homes—earlier, cheaper, and often better than can doctors. 4. Medical knowledge should not be the guarded secret of a select few, but should be freely shared by everyone. 5. People with little formal education can be trusted as much as those with a lot. And they are just as smart. 6. Basic health care should not be delivered, but encouraged. Clearly, a part of informed self-care is knowing one’s own limits. Therefore guidelines are included not only for what to do, but for when to seek help. The book points out those cases when it is important to see or get advice from a health worker or doctor. But because doctors or health workers are not always nearby, the book also suggests what to do in the meantime—even for very serious problems. This book has been written in fairly basic English, so that persons without much formal education (or whose first language is not English) can understand it. The language used is simple but, I hope, not childish. A few more difficult words have been used where they are appropriate or fit well. Usually they are used in ways that their meanings can be easily guessed. This way, those who read this book have a chance to increase their language skills as well as their medical skills. Important words the reader may not understand are explained in a word list or vocabulary at the end of the book. The first time a word listed in the vocabulary is mentioned in a chapter it is usually written in italics. Where There Is No Doctor was first written in Spanish for farm people in the mountains of Mexico where, 27 years ago, the author helped form a health care network now run by the villagers themselves. Where There Is No Doctor has been translated into more than 50 languages and is used by village health workers in over 100 countries.
  9. 9. The first English edition was the result of many requests to adapt it for use in Africa and Asia. I received help and suggestions from persons with experience in many parts of the world. But the English edition seems to have lost much of the flavor and usefulness of the original Spanish edition, which was written for a specific area, and for people who have for years been my neighbors and friends. In rewriting the book to serve people in many parts of the world, it has in some ways become too general. To be fully useful, this book should be adapted by persons familiar with the health needs, customs, special ways of healing, and local language of specific areas. • Persons or programs who wish to use this book, or portions of it, in preparing their own manuals for villagers or health workers are encouraged to do so. Permission from the author or publisher is not needed—provided the parts reproduced are distributed free or at cost—not for profit. It would be appreciated if you would (1) include a note of credit and (2) send a copy of your production to Hesperian, 1919 Addison St., #304, Berkeley, California 94704, U.S.A. For local or regional health programs that do not have the resources for revising this book or preparing their own manuals, it is strongly suggested that if the present edition is used, leaflets or inserts be supplied with the book to provide additional information as needed. In the Green Pages (the Uses, Dosage, and Precautions for Medicines) blank spaces have been left to write in common brand names and prices of medicines. Once again, local programs or organizations distributing the book would do well to make up a list of generic or low-cost brand names and prices, to be included with each copy of the book. • This book was written for anyone who wants to do something about his or her own and other people’s health. However, it has been widely used as a training and work manual for community health workers. For this reason, an introductory section has been added for the health worker, making clear that the health worker’s first job is to share her knowledge and help educate people. Today in over-developed as well as under-developed countries, existing health care systems are in a state of crisis. Often, human needs are not being well met. There is too little fairness. Too much is in the hands of too few. Let us hope that through a more generous sharing of knowledge, and through learning to use what is best in both traditional and modern ways of healing, people everywhere will develop a kinder, more sensible approach to caring—for their own health, and for each other. —D.W.
  10. 10. note about thIs new edItIon In this revised edition of Where There is No Doctor, we have added new information and updated old information, based on the latest scientific knowledge. Health care specialists from many parts of the world have generously given advice and suggestions. When it would fit without having to change page numbers, we have added new information to the main part of the book. (This way, the numbering stays the same, so that page references in our other books, such as Helping Health Workers Learn, will still be correct.) The Blue Pages—a section at the end of the book (p. 399)—has information about health problems of growing or special concern: HIV/AIDS, sores on the genitals, leishmaniasis, complications from abortion, guinea worm, and others. Here also are new topics such as measuring blood pressure, misuse of pesticides, drug addiction, and a method of caring for early and underweight babies. New ideas and information can be found throughout the book—medical knowledge is always changing! For example: • Nutrition advice has changed. Experts used to tell mothers to give children more foods rich in proteins. But it is now known that what most poorly nourished children need is more energy-rich foods. Many low-cost energy foods, especially grains, provide enough protein if the child eats enough of them. Finding ways to give enough energy foods is now emphasized, instead of the ‘four food groups’. (See Chapter 11.) • Advice for treatment of stomach ulcer is different nowadays. For years doctors recommended drinking lots of milk. But according to recent studies, it is better to drink lots of water, not milk. (See p. 129.) • Knowledge about special drinks for diarrhea (oral rehydration therapy) has also changed. Not long ago experts thought that drinks made with sugar were best. But we now know that drinks made with cereals do more to prevent water loss, slow down diarrhea, and combat malnutrition than do sugar-based drinks or “ORS” packets. (See p. 152.) • A section has been added on sterilizing equipment. This is important to prevent the spread of certain diseases, such as HIV/AIDS. (See p. 74.) • We have also added sections on dengue (p. 187), sickle cell disease (p. 321), and contraceptive implants (p. 293). Page 105 contains revised information about treatment of snakebite. • See page 139 for details on building the fly-killing VIP latrine.
  11. 11. If you have suggestions for improving this book, please let us know. Your ideas are very important to us! The Green Pages now include some additional medicines. This is because some diseases have become resistant to the medicines that were used in the past. So it is now harder to give simple medical advice for certain diseases—especially malaria, tuberculosis, typhoid, and sexually spread diseases. Often we give several possibilities for treatment. But for many infectious diseases you will need local advice about which medicines are available and effective in your area. In updating the information on medicines, we mostly include only those on the World Health Organization’s List of Essential Drugs. (However we also discuss some widely used but dangerous medicines to give warnings and to discourage their use— see also pages 50 to 52.) In trying to cover health needs and variations in many parts of the world, we have listed more medicines than will be needed for any one area. To persons preparing adaptations of this book, we strongly suggest that the Green Pages be shortened and modified to meet the specific needs and treatment patterns in your country. In this new edition of Where There Is No Doctor we continue to stress the value of traditional forms of healing, and have added some more “home remedies.” However, since many folk remedies depend on local plants and customs, we have added only a few which use commonly found items such as garlic. We hope those adapting this book will add home remedies useful to their area. Community action is emphasized throughout this book. For example, today it is often not enough to explain to mothers that ‘breast is best’. Communities must organize to make sure that mothers are able to breast feed their babies at work. Likewise, problems such as misuse of pesticides (p. 412), drug abuse (p. 416), and unsafe abortions (p. 414) are best solved by people working together to make their communities safer, healthier, and more fair. “Health for all” can be achieved only through the organized demand by people for greater equality in terms of land, wages, services, and basic rights. More power to the people!
  12. 12. Library of Congress Cataloging-in-Publication Data Werner, David, 1934- Where there is no doctor: a village health care handbook / by David Werner; with Carol Thuman and Jane Maxwell-Rev. ed. Includes Index. ISBN 0-942364-15-5 1. Medicine, Popular. 2. Rural health. I. Thuman, Carol, 1959-. II. Maxwell, Jane, 1941-. III Title. [DNLM: 1. Community Health Aides-handbooks. 2. Medicine-popular works. 3. Rural Health-handbooks. WA 39 W492W] RC81.W4813 1992 610-dc20 DNLM/DLC 92-1539 for Library of Congress CIP Published by: Hesperian 1919 Addison St., #304 Berkeley, California 94704 • USA hesperian@hesperian.org • www.hesperian.org Copyright © 1977, 1992, 2009 by the Hesperian Foundation First English edition: October 1977 Revised English edition: May 1992 Tenth printing: April 2009 The original English version of this book was produced in 1977 as a revised translation of the Spanish edition, Donde no hay doctor. Hesperian encourages others to copy, reproduce, or adapt to meet local needs, any or all parts of this book, including the illustrations, provided the parts reproduced are distributed free or at cost—not for profit. Any organization or person who wishes to copy, reproduce, or adapt any or all parts of this book for commercial purposes, must first obtain permission to do so from Hesperian. Please contact Hesperian before beginning any translation or adaptation to avoid duplication of efforts, and for suggestions about adapting the information in this book. The Foundation would appreciate receiving a copy of any materials in which text or illustrations from this book have been used. This book has been printed by union labor at Transcontinental Printers in Canada. THIS REVISED EDITION CAN BE IMPROVED WITH YOUR HELP. If you are a community health worker, doctor, mother, or anyone with ideas or suggestions for ways this book could be changed to better meet the needs of your community, please write to Hesperian at the above address. Thank you for your help.
  13. 13. Thanks to the work and dedication of many groups and individuals around the world, Where There Is No Doctor has been translated into more than 80 languages. The following are some of the translations and the addresses where you can obtain them. SPANISH and ENgLISH editions are available from: Hesperian 1919 Addison St., #304 • Berkeley, California 94704 • USA www.hesperian.org • bookorders@hesperian.org tel: (510) 845-4507 •fax: (510) 845-0539 SWAHILI: NEPALI: Rotary Club of Dar es Salaam Health Learning Materials Ctr. PO Box 1520 Institute of Medicine Dar es Salaam P.O. Box 2533 TANZANIA Kathmandu, NEPAL www.iom.edu.np/hlmc.html ARABIC: RUSSIAN: Arab Resource Collective Scientific Technology and P.O. Box 13-5916 Language Institute (STLI) Beirut, LEBANON P.O. Box 671 www.mawared.org Bishkek, 720017 KYRGYZSTAN HINDI: www.stli.org VHAI B-40, Qutab Institutional Area URDU: South of I.I.T. Pakistan Medical Association New Delhi, 110 016 PMA House,Garden Road INDIA Karachi 74400 www.vhai.org PAKISTAN INDONESIAN: HATIAN CREOLE: Yayasan Essentia Medica Life Publishers International PO Box 1058 1400 N. Campbell Yogyakarta, 55010 Springfield MO 65902 INDONESIA UNITED STATES Please write to Hesperian or look on our website at www.hesperian.org/publications_ translations.php for other editions including Albanian, Amharic, Aymara, Bengali, Burmese, Cebuano, Chichewa, Chinese, Dari, Farsi, French, Fulfide, German, Ilongo, Italian, Jinghpaw, Kannada, Karakalpak, Kazakh, Korean, Lao, Malayalam, Marathi, Marshallese, Oriya, Portuguese, Pashto, Quechua, Somali, Tamil, Telegu, Thai, Tibetan, Tigrinya, Turkish, Vietnamese, and Zulu, as well as other English editions adapted for specific countries. We are looking for ways to get this book to those it can serve best. If you are able to help or have suggestions, please contact Hesperian. We offer this book at a lower price to persons of low income living in poor countries.
  14. 14. THANKS This revision of Where There Is No Doctor has been a cooperative effort. We thank the many users of the book around the world who have written us over the years with comments and suggestions—these have guided us in updating this information. David Werner is the author of the original Spanish and English versions of the book. His vision, caring, and commitment are present on every page. Carol Thuman and Jane Maxwell share credit for most of the research, writing, and preparation of this revised version. We are deeply grateful for their excellent and very careful work. Thanks also to other researchers of this revised edition: Suellen Miller, Susan Klein, Ronnie Lovich, Mary Ellen Guroy, Shelley Kahane, Paula Elster, and George Kent. For information from the African edition, our thanks to Andrew Pearson and the other authors at Macmillan Publishers. Many doctors and health care specialists from around the world generously reviewed portions of the book. We cannot list them all here, but the help of the following was exceptional: David Sanders, Richard Laing, Bill Bower, Greg Troll, Deborah Bickel, Tom Frieden, Jane Zucker, David Morley, Frank Catchpool, Lonny Shavelson, Rudolph Bock, Joseph Cook, Sadja Greenwood, Victoria Sheffield, Sherry Hilaski, Pam Zinkin, Fernando Viteri, Jordan Tapero, Robert Gelber, Ted Greiner, Stephen Gloyd, Barbara Mintzes, Rainer Arnhold, Michael Tan, Brian Linde, Davida Coady, and Alejandro de Avila. Their expert advice and help have been of great value. We warmly thank the dedicated members of Hesperian for their help in preparing the manuscript: Kyle Craven for computer graphic arts and layout, Stephen Babb and Cynthia Roat for computer graphics, and Lisa de Avila for editorial assistance. We are also grateful to many others who helped in this book’s preparation: Kathy Alberts, Mary Klein, Evan Winslow- Smith, Jane Bavelas, Kim Gannon, Heidi Park, Laura Gibney, Nancy Ogaz, Martín Bustos, Karen Woodbury, and Trude Bock. Our special thanks to Keith and Luella McFarland for being there when we needed them most. For help updating this book, we thank Manisha Aryal, Marcos Burgos, Pam Fadem, Iñaki Fernández de Retana, Shu Ping Guan, Todd Jailer, Erika Leemann, Malcolm Lowe, Malini Mahendra, Jane Maxwell, Susan McCallister, Gail McSweeney, Elena Metcalf, Syema Muzaffar, Leana Rosetti, C. Sienkiewicz, Lora Santiago, Peter Small, Melissa Smith, Fred Strauss, Michael Terry, Fiona Thomson, Kathleen Vickery, and Sarah Wallis. Todd Jailer coordinated this 2009 reprint with help from Elizabeth Babu, Dan Eisenberg, Jacob Goolkasian, Shu Ping Guan, Jane Maxwell, Susan McCallister and Curt Wands. Artwork for this book was created by David Werner, Kyle Craven, Shu Ping Guan, Susan Klein, Regina Faul-Doyle, Sandy Frank, Fiona Thomson, and Lihua Wang. We also thank the following persons and groups for permission to use their artwork: Dale Crosby, Carl Werner, Macmillan Publishers (for some of Felicity Shepherd’s drawings in the African edition of this book), the “New Internationalist” (for the picture of the VIP latrine), James Ogwang (for the drawings on page 417), and McGraw-Hill Book Company (for drawings appearing on pages 85 and 104 taken from Emergency Medical Guide by John Henderson, illustrated by Niel Hardy). The fine work of those who helped in the creation of the original version is still reflected on nearly every page. Our thanks to Val Price, Al Hotti, Rodney Kendall, Max Capestany, Rudolf Bock, Kent Benedict, Alfonzo Darricades, Carlos Felipe Soto Miller, Paul Quintana, David Morley, Bill Bower, Allison Orozco, Susan Klein, Greg Troll, Carol Westburg, Lynn Gordon, Myra Polinger, Trude Bock, Roger Buch, Lynne Coen, George Kent, Jack May, Oliver Bock, Bill Gonda, Ray Bleicher, and Jesús Manjárrez. For this 1992 edition, we are grateful for financial support from the Carnegie Corporation, Gladys and Merrill Muttart Foundation, Myra Polinger, the Public Welfare Foundation, Misereor, the W.K. Kellogg Foundation, the Sunflower Foundation, and the Edna McConnell Clark Foundation. For this 2009 printing, thanks to Flora Family Foundation, Ford Foundation, Grousebeck Family Foundation, Moriah Fund, and West Foundation. Finally, our warm thanks to the village health workers of Project Piaxtla in rural Mexico —especially Martín Reyes, Miguel Angel Manjárrez, Miguel Angel Alvarez, and Roberto Fajardo whose experience and commitment have provided the foundation for this book.
  15. 15. Words to the Village health Worker Who is the village health worker? A village health worker is a person who helps lead family and neighbors toward better health. Often he or she has been selected by the other villagers as someone who is especially able and kind. Some village health workers receive training and help from an organized program, perhaps the Ministry of Health. Others have no official position, but are simply members of the community whom people respect as healers or leaders in matters of health. Often they learn by watching, helping, and studying on their own. In the larger sense, a village health worker is anyone who takes part in making his or her village a healthier place to live. This means almost everyone can and should be a health worker: • Mothers and fathers can show their children how to keep clean; • Farm people can work together to help their land produce more food; • Teachers can teach schoolchildren how to prevent and treat many common sicknesses and injuries; • Schoolchildren can share what they learn with their parents; • Shopkeepers can find out about the correct use of medicines they sell and give sensible advice and warning to buyers (see p. 338); • Midwives can counsel parents about the importance of eating well during pregnancy, breast feeding, and family planning. This book was written for the health worker in the larger sense. It is for anyone who wants to know and do more for his own, his family’s or his people’s well-being. If you are a community health worker, an auxiliary nurse, or even a doctor, remember: this book is not just for you. It is for all the people. Share it! Use this book to help explain what you know to others. Perhaps you can get small groups together THE VILLAGE HEALTH WORKER LIVES AND to read a chapter at a time and WORKS AT THE LEVEL OF HIS PEOPLE. HIS discuss it. FIRST JOB IS TO SHARE HIS KNOWLEDGE. w1
  16. 16. Where There Is No Doctor 2009 Dear Village Health Worker, This book is mostly about people’s health needs. But to help your village be a healthy place to live, you must also be in touch with their human needs. Your understanding and concern for people are just as important as your knowledge of medicine and sanitation. Here are some suggestions that may help you serve your people’s human needs as well as health needs: 1. BE KIND. A friendly word, a smile, a hand on the shoulder, or some other sign of caring often means more than anything else you can do. Treat others as your equals. Even when you are hurried or worried, try to remember the feelings and needs of others. Often it helps to ask yourself, “What would I do if this were a member of my own family?” Treat the sick as people. Be HAVE COMPASSION. especially kind to those who are very sick or dying. And be kind to their families. Let Kindness often helps more than medicine. Never be afraid to show them see that you care. you care. 2. SHARE YOUR KNOWLEDGE. As a health worker, your first job is to teach. This means helping people learn more about how to keep from getting sick. It also means helping people learn how to recognize and manage their illnesses—including the sensible use of home remedies and common medicines. There is nothing you have learned that, if carefully explained, should be of danger to anyone. Some doctors talk about self-care as if it were dangerous, perhaps because they like people to depend on their costly services. But in truth, most common health problems could be handled earlier and better by people in their own homes. LOOK FOR WAYS TO SHARE YOUR KNOWLEDGE w2
  17. 17. Where There Is No Doctor 2009 3. RESPECT YOUR PEOPLE’S TRADITIONS AND IDEAS. Because you learn something about modern medicine does not mean you should no longer appreciate the customs and ways of healing of your people. Too often the human touch in the art of healing is lost when medical science moves in. This is too bad, because. . . If you can use what is best in modern medicine, together with what is best in traditional healing, the combination may be better than either one alone. In this way, you will be adding to your people’s culture, not taking away. Of course, if you see that some of the home cures or customs are harmful (for example, putting excrement on the freshly cut cord of a newborn baby), you will want to do something to change this. But do so carefully, with respect for those who believe in such things. Never just tell people they are wrong. Try to help them understand WHY they should do something differently. People are slow to change their attitudes and traditions, and with good reason. They are true to what they feel is right. And this we must respect. Modern medicine does not have all the answers either. It has helped solve some problems, yet has led to other, sometimes even bigger ones. People quickly come to depend too much on modern medicine and its experts, to overuse medicines, and to forget how to care for themselves and each other. So go slow—and always keep a deep respect for your people, their traditions, and their human dignity. Help them build on the knowledge and skills they already have. WORK WITH TRADITIONAL HEALERS AND MIDWIVES— NOT AGAINST THEM. Learn from them and encourage them to learn from you. w3
  18. 18. Where There Is No Doctor 2009 4. KNOW YOUR OWN LIMITS. No matter how great or small your knowledge and skills, you can do a good job as long as you know and work within your limits. This means: Do what you know how to do. Do not try things you have not learned about or have not had enough experience doing, if they might harm or endanger someone. But use your judgment. Often, what you decide to do or not do will depend on how far you have to go to get more expert help. For example, a mother has just given birth and is bleeding more than you think is normal. If you are only half an hour away from a medical center, it may be wise to take her there right KNOW YOUR LIMITS. away. But if the mother is bleeding very heavily and you are a long way from the health center, you may decide to massage her womb (see p. 265) or inject an oxytocic (see p. 266) even if you were not taught this. Do not take unnecessary chances. But when the danger is clearly greater if you do nothing, do not be afraid to try something you feel reasonably sure will help. Know your limits—but also use your head. Always do your best to protect the sick person rather than yourself. 5. KEEP LEARNING. Use every chance you have to learn more. Study whatever books or information you can lay your hands on that will help you be a better worker, teacher, or person. Always be ready to ask questions of doctors, sanitation officers, agriculture experts, or anyone else you can learn from. Never pass up the chance to take refresher courses or get additional training. Your first job is to teach, and unless you KEEP LEARNING—Do not let keep learning more, soon you will not have anyone tell you there are things anything new to teach others. you should not learn or know. w4
  19. 19. Where There Is No Doctor 2009 6. PRACTICE WHAT YOU TEACH. People are more likely to pay attention to what you do than what you say. As a health worker, you want to take special care in your personal life and habits, so as to set a good example for your neighbors. Before you ask people to make latrines, be sure your own family has one. Also, if you help organize a work group— for example, to dig a common garbage hole—be sure you work and sweat as hard as everyone else. Good leaders do not tell people what to do. They set the example. PRACTICE WHAT YOU TEACH (or who will listen to you?) 7. WORK FOR THE JOY OF IT. If you want other people to take part in improving their village and caring for their health, you must enjoy such activity yourself. If not, who will want to follow your example? Try to make community work projects fun. For example, fencing off the public water hole to keep animals away from where people take water can be hard work. But if the whole village helps do it as a ‘work festival’—perhaps with refreshments and music—the job will be done quickly and can be fun. Children will work hard and enjoy it, if they can turn work into play. You may or may not be paid for your work. But never refuse to care, or care less, for someone who is poor or cannot pay. This way you will win your people’s WORK FIRST FOR THE PEOPLE—NOT THE MONEY. love and respect. These (People are worth more.) are worth far more than money. w5
  20. 20. Where There Is No Doctor 2009 8. LOOK AHEAD—AND HELP OTHERS TO LOOK AHEAD. A responsible health worker does not wait for people to get sick. She tries to stop sickness before it starts. She encourages people to take action now to protect their health and well-being in the future. Many sicknesses can be prevented. Your job, then, is to help your people understand the causes of their health problems and do something about them. Most health problems have many causes, one leading to another. To correct the problem in a lasting way, you must look for and deal with the underlying causes. You must get to the root of the problem. For example, in many villages diarrhea is the most common cause of death in small children. The spread of diarrhea is caused in part by lack of cleanliness (poor sanitation and hygiene). You can do something to correct this by digging latrines and teaching basic guidelines of cleanliness (p. 133). But the children who suffer and die most often from diarrhea are those who are poorly nourished. Their bodies do not have strength to fight the infections. So to prevent death from diarrhea we must also prevent poor nutrition. And why do so many children suffer from poor nutrition? • Is it because mothers do not realize what foods are most important (for example, breast milk)? • Is it because the family does not have enough money or land to produce the food it needs? • Is it because a few rich persons control most of the land and the wealth? • Is it because the poor do not make the best use of land they have? • Is it because parents have more children than they or their land can provide for, and keep having more? • Is it because fathers lose hope and spend the little money they have on drink? • Is it because people do not look or plan ahead? Because they do not realize that by working together and sharing they can change the conditions under which they live and die? HELP OTHERS TO LOOK AHEAD. w6
  21. 21. Where There Is No Doctor 2009 You may find that many, if not all, of these things lie behind infant deaths in your area. You will, no doubt, find other causes as well. As a health worker it is your job to help people understand and do something about as many of these causes as you can. But remember: to prevent frequent deaths from diarrhea will take far more than latrines, pure water, and ‘special drink’ (oral rehydration). You may find that child spacing, better land use, and fairer distribution of wealth, land, and power are more important in the long run. The causes that lie behind much sickness and human suffering are short-sightedness and greed. If your interest is your people’s well-being, you must help them learn to share, to work together, and to look ahead. MANY THINGS RELATE TO HEALTH CARE We have looked at some of the causes that underlie diarrhea and poor nutrition. Likewise, you will find that such things as food production, land distribution, education, and the way people treat The chain of causes leading or mistreat each other lie behind many to death from diarrhea. different health problems. If you are interested in the long-term welfare of your whole community, you must help your people look for answers to these larger questions. Health is more than not being sick. It is well-being: in body, mind, and community. People live best in healthy surroundings, in a place where they can trust each other, work together to meet daily needs, share in times of difficulty and plenty, and help each other learn and grow and live, each as fully as he or she can. Do your best to solve day-to-day problems. But remember that your greatest job is to help your community become a more healthy and more human place to live. You as a health worker have a big responsibility. Where should you begin? w7
  22. 22. Where There Is No Doctor 2009 TAKE A GOOD LOOK AT YOUR COMMUNITY Because you have grown up in your community and know your people well, you are already familiar with many of their health problems. You have an inside view. But in order to see the whole picture, you will need to look carefully at your community from many points of view. As a village health worker, your concern is for the well-being of all the people—not just those you know well or who come to you. Go to your people. Visit their homes, fields, gathering places, and schools. Understand their joys and concerns. Examine with them their habits, the things in their daily lives that bring about good health, and those that may lead to sickness or injury. Before you and your community attempt any project or activity, carefully think about what it will require and how likely it is to work. To do this, you must consider all the following: 1. Felt needs—what people feel are their biggest problems. 2. Real needs—steps people can take to correct these problems in a lasting way. 3. Willingness—or readiness of people to plan and take the needed steps. 4. Resources—the persons, skills, materials, and/or money needed to carry out the activities decided upon. As a simple example of how each of these things can be important, let us suppose that a man who smokes a lot comes to you complaining of a cough that has steadily been getting worse. 1. His felt need is to get rid of his cough. 2. His real need (to correct the problem) is to give up smoking. 4. One resource that may help him give up 3. To get rid of his cough will require his smoking is information about the harm it can do willingness to give up smoking. For this he him and his family (see p. 149). Another is the must understand how much it really support and encouragement of his family, his matters. friends, and you. w8
  23. 23. Where There Is No Doctor 2009 Finding Out the Needs As a health worker, you will first want to find out your people’s most important health problems and their biggest concerns. To gather the information necessary to decide what the greatest needs and concerns really are, it may help to make up a list of questions. On the next 2 pages are samples of the kinds of things you may want to ask. But think of questions that are important in your area. Ask questions that not only help you get information, but that get others asking important questions themselves. Do not make your list of questions too long or complicated—especially a list you take from house to house. Remember, people are not numbers and do not like to be looked at as numbers. As you gather information, be sure your first interest is always in what individuals want and feel. It may be better not even to carry a list of questions. But in considering the needs of your community, you should keep certain basic questions in mind. w9
  24. 24. Where There Is No Doctor 2009 Sample Lists Of Questions To Help Determine Community Health Needs And at the Same Time Get People Thinking FELT NEEDS What things in your people’s daily lives (living conditions, ways of doing things, beliefs, etc.) do they feel help them to be healthy? What do people feel to be their major problems, concerns, and needs—not only those related to health, but in general? HOUSING AND SANITATION What are different houses made of? Walls? Floors? Are the houses kept clean? Is cooking done on the floor or where? How does smoke get out? On what do people sleep? Are flies, fleas, bedbugs, rats, or other pests a problem? In what way? What do people do to control them? What else could be done? Is food protected? How could it be better protected? What animals (dogs, chickens, pigs, etc.), if any, are allowed in the house? What problems do they cause? What are the common diseases of animals? How do they affect people’s health? What is being done about these diseases? Where do families get their water? Is it safe to drink? What precautions are taken? How many families have latrines? How many use them properly? Is the village clean? Where do people put garbage? Why? POPULATION How many people live in the community? How many are under 15 years old? How many can read and write? What good is schooling? Does it teach children what they need to know? How else do children learn? How many babies were born this year? How many people died? Of what? At what ages? Could their deaths have been prevented? How? Is the population (number of people) getting larger or smaller? Does this cause any problems? How often were different persons sick in the past year? How many days was each sick? What sickness or injuries did each have? Why? How many people have chronic (long-term) illnesses? What are they? How many children do most parents have? How many children died? Of what? At what ages? What were some of the underlying causes? How many parents are interested in not having any more children or in not having them so often? For what reasons? (See Family Planning, p. 283.) w10
  25. 25. Where There Is No Doctor 2009 NUTRITION How many mothers breast feed their babies? For how long? Are these babies healthier than those who are not breast fed? Why? What are the main foods people eat? Where do they come from? Do people make good use of all foods available? How many children are underweight (p. 109) or show signs of poor nutrition? How much do parents and school children know about nutritional needs? How many people smoke a lot? How many drink alcoholic or soft drinks very often? What effect does this have on their own and their families’ health? (See p. 148 to 150.) LAND AND FOOD Does the land provide enough food for each family? How long will it continue to produce enough food if families keep growing? How is farm land distributed? How many people own their land? What efforts are being made to help the land produce more? How are crops and food stored? Is there much damage or loss? Why? HEALING, HEALTH What role do local midwives and healers play in health care? What traditional ways of healing and medicines are used? Which are of greatest value? Are any harmful or dangerous? What health services are nearby? How good are they? What do they cost? How much are they used? How many children have been vaccinated? Against what sicknesses? What other preventive measures are being taken? What others might be taken? How important are they? SELF-HELP What are the most important things that affect your people’s health and well-being—now and in the future? How many of their common health problems can people care for themselves? How much must they rely on outside help and medication? Are people interested in finding ways of making self-care safer, more effective and more complete? Why? How can they learn more? What stands in the way? What are the rights of rich people? Of poor people? Of men? Of women? Of children? How is each of these groups treated? Why? Is this fair? What needs to be changed? By whom? How? Do people work together to meet common needs? Do they share or help each other when needs are great? What can be done to make your village a better, healthier place to live? Where might you and your people begin? w11
  26. 26. Where There Is No Doctor 2009 USING LOCAL RESOURCES TO MEET NEEDS How you deal with a problem will depend upon what resources are available. Some activities require outside resources (materials, money, or people from somewhere else). For example, a vaccination program is possible only if vaccines are brought in—often from another country. Other activities can be carried out completely with local resources. A family or a group of neighbors can fence off a water hole or build simple latrines using materials close at hand. Some outside resources, such as vaccines and a few important medicines, can make a big difference in people’s health. You should do your best to get them. But as a general rule, it is in the best interest of your people to Use local resources whenever possible. The more you and your Encourage people to make people can do for yourselves, the most of local resources. and the less you have to depend on outside assistance and supplies, the healthier and stronger your community will become. Not only can you count on local resources to be on hand when you need them, but often they do the best job at the lowest cost. For example, if you can encourage mothers to breast feed their babies, this will build self-reliance through a top quality local resource— breast milk! It will also prevent needless sickness and death of many babies. BREAST MILK—A TOP QUALITY LOCAL RESOURCE—BETTER THAN In your health work always ANYTHING MONEY CAN BUY! remember: The most valuable resource for the health of the people is the people themselves. w12
  27. 27. Where There Is No Doctor 2009 DECIDING WHAT TO DO AND WHERE TO BEGIN After taking a careful look at needs and resources, you and your people must decide which things are more important and which to do first. You can do many different things to help people be healthy. Some are important immediately. Others will help determine the future well-being of individuals or the whole community. In a lot of villages, poor nutrition plays a part in other health problems. People cannot be healthy unless there is enough to eat. Whatever other problems you decide to work with, if people are hungry or children are poorly nourished, better nutrition must be your first concern. There are many different ways to approach the problem of poor nutrition, for many different things join to cause it. You and your community must consider the possible actions you might take and decide which are most likely to work. Here are a few examples of ways some people have helped meet their needs for better nutrition. Some actions bring quick results. Others work over a longer time. You and your people must decide what is most likely to work in your area. POSSIBLE WAYS TO WORK TOWARD BETTER NUTRITION FAMILY GARDENS CONTOUR DITCHES to prevent soil from washing away ROTATION OF CROPS Every other planting season plant a crop that returns strength to the soil—like beans, peas, lentils, alfalfa, peanuts or some other plant with seed in pods (legumes). This year maize Next year beans w13
  29. 29. Where There Is No Doctor 2009 TRYING A NEW IDEA Not all the suggestions on the last pages are likely to work in your area. Perhaps some will work if changed for your particular situation and resources at hand. Often you can only know whether something will work or not by trying it. That is, by experiment. When you try out a new idea, always start small. If you start small and the experiment fails, or something has to be done differently, you will not lose much. If it works, people will see that it works Start small and can begin to apply it in a bigger way. Do not be discouraged if an experiment does not work. Perhaps you can try again with certain changes. You can learn as much from your failures as your successes. But start small. Here is an example of experimenting with a new idea. You learn that a certain kind of bean, such as soya, is an excellent body-building food. But will it grow in your area? And if it grows, will people eat it? Start by planting a small patch—or 2 or 3 small patches in different conditions of soil or water. If the beans do well, try preparing them in different ways, and see if people will eat them. If so, try planting more beans in the conditions where you found they grew best. But try out still other conditions in more small patches to see if you can get an even better crop. There may be several conditions you want to try changing. For example, type of soil, addition of fertilizer, amount of water, or different varieties of seed. To best understand what helps and what does not, be sure to change only one condition at a time and keep all the rest the same. For example, to find out if animal fertilizer (manure) helps the beans grow, and how much to use, plant several small bean patches side by side, under the same conditions of water and sunlight, and using the same seed. But before you plant, mix each patch with a different amount of manure, something like this: This experiment shows that a certain amount of manure helps, but that too much can harm the plants. This is only an example. You experiments may give different results. Try for yourself! w15
  30. 30. Where There Is No Doctor 2009 WORKING TOWARD A BALANCE BETWEEN PEOPLE AND LAND Health depends on many things, but above all it depends on whether people have enough to eat. Most food comes from the land. Land that is used well can produce more food. A health worker needs to know ways to help the land better feed the people—now and in the future. But even the best used piece of land can only feed a certain number of people. And today, many of the people who farm do not have enough land to meet their needs or to stay healthy. In many parts of the world, the situation is getting worse, not better. Parents often have many children, so year by year there are more mouths to feed on the limited land that the poor are permitted to use. Many health programs try to work toward a balance between people and land through ‘family planning,’ or helping people have only the number of children they want. Smaller families, they reason, will mean more land and food to go around. But family planning by itself has little effect. As long as people are very poor, they often want many children. Children help with work without having to be paid, and as they get bigger may even bring home a little money. When the parents grow old, some of their children—or grandchildren—will perhaps be able to help care for them. For a poor country to have many children may be an economic disaster. But for a poor family to have many children is often an economic necessity—especially when many die young. In the world today, for most people, having many children is the surest form of social security they can hope for. Some groups and programs take a different approach. They recognize that hunger exists not because there is too little land to feed everyone, but because most of the land is in the hands of a few selfish persons. The balance they seek is a fairer distribution of land and wealth. They work to help people gain greater control over their health, land, and lives. It has been shown that, where land and wealth are shared more fairly and people gain greater economic security, they usually choose to have smaller families. Family planning helps when it is truly the people’s choice. A balance between people and land can more likely be gained through helping people work toward fairer distribution and social justice than through family planning alone. It has been said that the social meaning of love is justice. The health worker who loves her people should help them work toward a balance based on a more just distribution of land and wealth. w16
  31. 31. Where There Is No Doctor 2009 WORKING TOWARD A BALANCE BETWEEN A balance between treatment and prevention often comes down to a balance between immediate needs and long-term needs. As a health worker you must go to your people, work with them on their terms, and help them find answers to the needs they feel most. People’s first concern is often to find relief for the sick and suffering. Therefore, one of your first concerns must be to help with healing. But also look ahead. While caring for people’s immediate felt needs, also help them look to the future. Help them realize that much sickness and suffering can be prevented and that they themselves can take preventive actions. But be careful! Sometimes health planners and workers go too far. In their eagerness to prevent future ills, they may show too little concern for the sickness and suffering that already exist. By failing to respond to people’s present needs, they may fail to gain their cooperation. And so they fail in much of their preventive work as well. Treatment and prevention go hand in hand. Early treatment often prevents mild illness from becoming serious. If you help people to recognize many of their common health problems and to treat them early, in their own homes, much needless suffering can be prevented. Early treatment is a form of preventive medicine. If you want their cooperation, start where your people are. Work toward a balance between prevention and treatment that is acceptable to them. Such a balance will be largely determined by people’s present attitudes toward sickness, healing, and health. As you help them look farther ahead, as their attitudes change, and as more diseases are controlled, you may find that the balance shifts naturally in favor of prevention. You cannot tell the mother whose child is ill that prevention is more important than cure. Not if you want her to listen. But you can tell her, while you help her care for her child, that prevention is equally important. Work toward prevention—do not force it. Use treatment as a doorway to prevention. One of the best times to talk to people about prevention is when they come for treatment. For example, if a mother brings a child with worms, carefully explain to her how to treat him. But also take time to explain to both the mother and child how the worms are spread and the different things they can do to prevent this from happening (see Chapter 12). Visit their home from time to time, not to find fault, but to help the family toward more effective self-care. Use treatment as a chance to teach prevention. w17
  32. 32. Where There Is No Doctor 2009 SENSIBLE AND LIMITED USE OF MEDICINES One of the most difficult and important parts of preventive care is to educate your people in the sensible and limited use of medicines. A few modern medicines are very important and can save lives. But for most sicknesses no medicine is needed. The body itself can usually fight off sickness with rest, good food, drinking lots of liquid, and perhaps some simple home remedies. People may come to you asking for medicine when they do not need any. You may be tempted to give them some medicine just to please. But if you do, when they get well, they will think that you and the medicine cured them. Really their bodies cured themselves. Instead of teaching people to depend on medicines they do not need, take time to explain why they should not be used. Also tell people what they can do themselves to get well. This way you are helping people to rely on local resources (themselves), rather than on an outside resource (medicine). Also, you are protecting their health, for there is no medicine that does not have some risk in its use. Three common health problems for which people too often request medicines they do not need are (1) the common cold, (2) minor cough, and (3) diarrhea. The common cold is best treated by resting, drinking lots of liquids, and at the most taking aspirin. Penicillin, tetracycline, and other antibiotics do not help at all (see p. 163). For minor coughs, or even more severe coughs with thick mucus or phlegm, drinking a lot of water will loosen mucus and ease the cough faster and better than cough syrup. Breathing warm water vapor brings even greater relief (see p. 168). Do not make people dependent on cough syrup or other medicines they do not need. For most diarrhea of children, medicines do not make them get well. Many commonly used medicines (neomycin, streptomycin, kaolin-pectin, Lomotil, chloramphenicol) may even be harmful. What is most important is that the child get lots of liquids and enough food (see p. 155 to 156). The key to the child’s recovery is the mother, not the medicine. If you can help mothers understand this and learn what to do, many children’s lives can be saved. w18
  33. 33. Where There Is No Doctor 2009 Medicines are often used too much, both by doctors and by ordinary people. This is unfortunate for many reasons: • It is wasteful. Most money spent on medicine would be better spent on food. • It makes people depend on something they do not need (and often cannot afford). • Every medicine has some risk in its use. There is always a chance that an unneeded medicine may actually do the person harm. • What is more, when some medicines are used too often for minor problems, they lose their power to fight dangerous sicknesses. An example of a medicine losing its power is chloramphenicol. The extreme overuse of this important but risky antibiotic for minor infections has meant that in some parts of the world chloramphenicol no longer works against typhoid fever, a very dangerous infection. Frequent overuse of chloramphenicol has allowed typhoid to become resistant to it (see p. 58). For all the above reasons the use of medicines should be limited. But how? Neither rigid rules and restrictions nor permitting only highly trained persons to decide about the use of medicines has prevented overuse. Only when the people themselves are better informed will the limited and careful use of medicines be common. To educate people about sensible and limited use of medicines is one of the important jobs of the health worker. This is especially true in areas where modern medicines are already in great use. WHEN MEDICINES ARE NOT NEEDED, TAKE TIME TO EXPLAIN WHY. For more information about the use and misuse of medicines, see Chapter 6, page 49. For the use and misuse of injections, see Chapter 9, page 65. For sensible use of home remedies, see Chapter 1. w19
  34. 34. Where There Is No Doctor 2009 FINDING OUT WHAT PROGRESS HAS BEEN MADE (EVALUATION) From time to time in your health work, it helps to take a careful look at what and how much you and your people have succeeded in doing. What changes, if any, have been made to improve health and well-being in your community? You may want to record each month or year the health activities that can be measured. For example: • How many families have put in latrines? • How many farmers take part in activities to improve their land and crops? • How many mothers and children take part in an Under-Fives Program (regular check-ups and learning)? This kind of question will help you measure action taken. But to find out the result or impact of these activities on health, you will need to answer other questions such as: • How many children had diarrhea or signs of worms in the past month or year—as compared to before there were latrines? • How much was harvested this season (corn, beans, or other crops)—as compared to before improved methods were used? • How many children show normal weight and weight-gain on their Child Health Charts (see p. 297)—as compared to when the Under-Fives Program was started? • Do fewer children die now than before? To be able to judge the success of any activity you need to collect certain information both before and after. For example, if you want to teach mothers how important it is to breast feed their babies, first take a count of how many mothers are doing so. Then begin the teaching program and each year take another count. This way you can get a good idea as to how much effect your teaching has had. You may want to set goals. For example, you and the health committee may hope that 80% of the families have latrines by the end of one year. Every month you take a count. If, by the end of six months, only one-third of the families have latrines, you know you will have to work harder to meet the goal you set for yourselves. Setting goals often helps people work harder and get more done. To evaluate the results of your health activities it helps to count and measure certain things before, during, and after. But remember: The most important part of your health work cannot be measured. It has to do with the way you and other people relate to each other; with people learning and working together; with the growth of kindness, responsibility, sharing, and hope. It depends on the growing strength and unity of the people to stand up for their basic rights. You cannot measure these things. But weigh them well when you consider what changes have been made. w20
  35. 35. Where There Is No Doctor 2009 TEACHING AND LEARNING TOGETHER— THE HEALTH WORKER AS AN EDUCATOR As you come to realize how many things affect health, you may think the health worker has an impossibly large job. And true, you will never get much done if you try to deliver health care by yourself. Only when the people themselves become actively responsible for their own and their community’s health, can important changes take place. Your community’s well-being depends on the involvement not of one person, but of nearly everyone. For this to happen, responsibility and knowledge must be shared. This is why your first job as a health worker is to teach—to teach children, parents, farmers, schoolteachers, other health workers—everyone you can. The art of teaching is the most important skill a person can learn. To teach is to help others grow, and to grow with them. A good teacher is not someone who puts ideas into other people’s heads; he or she is someone who helps others build on their own ideas, to make new discoveries for themselves. Teaching and learning should not be limited to the schoolhouse or health post. They should take place in the home and in the fields and on the road. As a health worker one of your best chances to teach will probably be when you treat the sick. But you should look for every opportunity to exchange ideas, to share, to show, and to help your people think and work together. On the next few pages are some ideas that may help you do this. They are only suggestions. You will have many other ideas yourself. TWO APPROACHES TO HEALTH CARE w21
  36. 36. Where There Is No Doctor 2009 Tools for Teaching Flannel-graphs are good for talking with groups because you can keep making new pictures. Cover a square board or piece of cardboard with a flannel cloth. You can place different cutout drawings or photos on it. Strips of sandpaper or flannel glued to the backs of cutouts help them stick to the flannelboard. Posters and displays. “A picture is worth a thousand words.” Simple drawings, with or without a few words of information, can be hung in the health post or anywhere that people will look at them. You can copy some of the pictures from this book. If you have trouble getting sizes and shapes right, draw light, even squares in pencil over the picture you want to copy. Now draw the same number of squares lightly, but larger, on the poster paper or cardboard. Then copy the drawing, square for square. If possible, ask village artists to draw or paint posters. Or have children make posters on different subjects. Models and demonstrations help get ideas across. For example, if you want to talk with mothers and midwives about care in cutting the cord of a newborn child, you can make a doll for the baby. Pin a cloth cord to its belly. Experienced midwives can demonstrate to others. Color slides and filmstrips are available on different health subjects for many parts of the world. Some come in sets that tell a story. Simple viewers and battery-operated projectors are also available. A list of addresses where you can send for teaching materials to use for health education in your village can be found on pages 429 to 432. w22
  37. 37. Where There Is No Doctor 2009 Other Ways to Get Ideas Across Story telling. When you have a hard time explaining something, a story, especially a true one, will help make your point. For example, if I tell you that sometimes a village worker can make a better diagnosis than a doctor, you may not believe me. But if I tell you about a village health worker called Irene, who runs a small nutrition center in Central America, you may understand. One day a small sickly child arrived at the nutrition center. He had been sent by the doctor at a nearby health center because he was badly malnourished. The child also had a cough, and the doctor had prescribed a cough medicine. Irene was worried about the child. She knew he came from a very poor family and that an older brother had died a few weeks before. She went to visit the family and learned that the older brother had been very sick for a long time and had coughed blood. Irene went to the health center and told the doctor she was afraid the child had tuberculosis. Tests were made, and it turned out that Irene was right. . . . So you see, the health worker spotted the real problem before the doctor—because she knew her people and visited their homes. Stories also make learning more interesting. It helps if health workers are good story tellers. Play acting. Stories that make important points can reach people with even more force if they are acted out. Perhaps you, the schoolteacher, or someone on the health committee can plan short plays or ‘skits’ with the schoolchildren. For example, to make the point that food should be protected from flies to prevent the spread of disease, several small children could dress up as flies and buzz around food. The flies dirty the food that has not been covered. Then children eat this food and get sick. But the flies cannot get at food in a box with a wire screen front. So the children who eat this food stay well. The more ways you can find to share ideas, the more people will understand and remember. w23
  38. 38. Where There Is No Doctor 2009 Working and Learning Together for the Common Good There are many ways to interest and involve people in working together to meet their common needs. Here are a few ideas: 1. A village health committee. A group of able, interested persons can be chosen by the village to help plan and lead activities relating to the well-being of the community—for example, digging garbage pits or latrines. The health worker can and should share much of his responsibility with other persons. 2. Group discussions. Mothers, fathers, schoolchildren, young people, folk healers, or other groups can discuss needs and problems that affect health. Their chief purpose can be to help people share ideas and build on what they already know. 3. Work festivals. Community projects such as putting in a water system or cleaning up the village go quickly and can be fun if everybody helps. Games, races, refreshments, and simple prizes help turn work into play. Use imagination. 4. Cooperatives. People can help keep prices down by sharing tools, storage, and perhaps land. Group cooperation can have a big influence on people’s well-being. 5. Classroom visits. Work with the village schoolteacher to encourage health-related activities, through demonstrations and play acting. Also invite small groups of students to come to the health center. Children not only learn quickly, but they can help out in many ways. If you give children a chance, they gladly become a valuable resource. 6. Mother and child health meetings. It is especially important that pregnant women and mothers of small children (under five years old) be well informed about their own and their babies’ health needs. Regular visits to the health post are opportunities for both check-ups and learning. Have mothers keep their children’s health records and bring them each month to have their children’s growth recorded (see the Child Health Chart, p. 297). Mothers who understand the chart often take pride in making sure their children are eating and growing well. They can learn to understand these charts even if they cannot read. Perhaps you can help train interested mothers to organize and lead these activities. 7. Home visits. Make friendly visits to people’s homes, especially homes of families who have special problems, who do not come often to the health post, or who do not take part in group activities. But respect people’s privacy. If your visit cannot be friendly, do not make it—unless children or defenseless persons are in danger. w24
  39. 39. Where There Is No Doctor 2009 Ways to Share and Exchange Ideas in a Group As a health worker you will find that the success you have in improving your people’s health will depend far more on your skills as a teacher than on your medical or technical knowledge. For only when the whole community is involved and works together can big problems be overcome. People do not learn much from what they are told. They learn from what they think, feel, discuss, see, and do together. So the good teacher does not sit behind a desk and talk at people. He talks and works with them. He helps his people to think clearly about their needs and to find suitable ways to meet them. He looks for every opportunity to share ideas in an open and friendly way. Perhaps the most important thing you can do as a health worker is to awaken your people to their own possibilities. . . to help them gain confidence in themselves. Sometimes villagers do not change things they do not like because they do not try. Too often they may think of themselves as ignorant and powerless. But they are not. Most villagers, including those who cannot read or write, have remarkable knowledge and skills. They already make great changes in their surroundings with the tools they use, the land they farm, and the things they build. They can do many important things that people with a lot of schooling cannot. If you can help people realize how much they already know and have done to change their surroundings, they may also realize that they can learn and do even more. By working together it is within their power to bring about even bigger changes for their health and well-being. Then how do you tell people these things? Often you cannot! But you can help them find out some of these things for themselves—by bringing them together for discussions. Say little yourself, but start the discussion by asking certain questions. Simple pictures like the drawing on the next page of a farm family in Central America may help. You will want to draw your own picture, with buildings, people, animals, and crops that look as much as possible like those in your area. w25
  40. 40. Where There Is No Doctor 2009 USE PICTURES TO GET PEOPLE TALKING AND THINKING TOGETHER Show a group of people a picture similar to this and ask them to discuss it. Ask questions that get people talking about what they know and can do. Here are some sample questions: • Who are the people in the picture and how do they live? • What was this land like before the people came? • In what ways have they changed their surroundings? • How do these changes affect their health and well-being? • What other changes could these people make? What else could they learn to do? What is stopping them? How could they learn more? • How did they learn to farm? Who taught them? • If a doctor or a lawyer moved onto this land with no more money or tools than these people, could he farm it as well? Why or why not? • In what ways are these people like ourselves? w26
  41. 41. Where There Is No Doctor 2009 This kind of group discussion helps build people’s confidence in themselves and in their ability to change things. It can also make them feel more involved in their community. At first you may find that people are slow to speak out and say what they think. But after a while they will usually begin to talk more freely and ask important questions themselves. Encourage everyone to say what he or she feels and to speak up without fear. Ask those who talk most to give a chance to those who are slower to speak up. You can think of many other drawings and questions to start discussions that can help people look more clearly at problems, their causes, and possible solutions. • What questions can you ask to get people thinking about the different things that lead to the condition of the child in the following picture? Try to think of questions that lead to others and get people asking for themselves. How many of the causes underlying death from diarrhea (see p. w7) will your people think of when they discuss a picture like this? w27